ORIGINAL

ARTICLE
https://doi.org/10.14730/aaps.2018.01550
Arch Aesthetic Plast Surg 2019;25(2):52-58
pISSN: 2234-0831 eISSN: 2288-9337
aaps
Archives of
Aesthetic Plastic Surgery

Minimally invasive facial rejuvenation combining

thread lifting with liposuction: A clinical comparison
with thread lifting alone

Kwang Il Bae1, Dong Gil Han1,
Sung-Eun Kim1, Young Bae Lee2
Department of Plastic and
1
Background Barbed thread lifting is known to be a minimally invasive procedure com-
pared with standard incisional surgery for facial rejuvenation. However, some studies
have pointed out that the effects of thread lifting do not last long and disappear after

Reconstructive Surgery, School of

Medicine, Catholic University of Daegu,
Daegu; 2Lift Plastic Clinic, Daegu, Korea
This article was presented as a free paper at
the PRS Korea 2017 on November 12, 2017, in
Seoul, Korea
several months. Therefore, the aim of this study was to evaluate the efficiency and du-
ration of anchoring-type absorbable thread lifting combined with liposuction for facial
rejuvenation.
Methods A retrospective review of 27 cosmetic patients who underwent absorbable
barbed thread lifting with liposuction between July 2013 and December 2015 was un-
dertaken. The efficiency of facial rejuvenation was evaluated through a patient satis-
faction score and the global aesthetic improvement scale (GAIS).
Results Subjects were divided into two groups: thread lifting only and thread lifting
combined with liposuction. The mean follow-up period of each group was 8.5 and 9.3
months, respectively. In the thread lifting–only group, the average patient satisfaction
score was 2.36 (1=unsatisfied to 4=very satisfied), and the average GAIS score was 2.54
(1=very much improved to 5=worsen). In the thread lifting with liposuction group, the
average patient satisfaction score was 3.06, and the average GAIS score was 1.85.
Conclusions Thread lifting combined with liposuction showed better patient satisfac-
tion and GAIS results than thread lifting alone, even over a long follow-up period.
Keywords Suture anchors / Lipectomy / Rejuvenation

INTRODUCTION have been devised [1,2].

Facial aging is characterized by a progressive increase in the laxity
of skin and soft tissue, superficial skin changes, and volume loss.
Due to advances in the understanding and comprehension of these
processes, many operations and procedures for facial rejuvenation
Received: Dec 6, 2018 Revised: Feb 18, 2019 Accepted: Mar 22, 2019
Correspondence: Dong Gil Han Department of Plastic and Reconstructive
Surgery, School of Medicine, Catholic University of Daegu, 33
Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea
Tel: +82-53-650-4474, Fax: +82-53-650-4584, E-mail: dghan1001@cu.ac.kr
Copyright © 2019 The Korean Society for Aesthetic Plastic Surgery.
This is an Open Access article distributed under the terms of the Creative Commons At-
tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)
which permits unrestricted non-commercial use, distribution, and reproduction in any
medium, provided the original work is properly cited. www.e-aaps.org
However, patients now prefer minimally invasive procedures,
which have few complications, allow a rapid recovery, and enable
patients to quickly return to their daily activities [3]. Thread lifting
is a minimally invasive procedure for facial rejuvenation that was
introduced by Sulamanidze et al. [4] and has been recognized as a
safe procedure with few major or minor complications.
However, some studies have pointed out that the facial rejuve-
nating effect after a procedure is lost over the course of long-term
follow-up. Other studies have argued that thread lifting has limita-
tions in terms of accomplishing the goals of facial rejuvenation, as
it has little effectiveness and a short period of efficacy [5]. To re-
solve these concerns, other cosmetic procedures, such as fat grafts,
laser treatment, and filler injections, have been combined with thread
lifting [6,7].
In this study, we combined absorbable thread lifting with lipo-

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Aesthetic Plastic Surgery

suction and compared the outcomes of this combined procedure terval distance of each thread was 1 cm. The route of the threads
with those of conventional absorbable thread lifting alone, focusing meant that the direction of lifting was almost vertical. The anchor
on both the rejuvenating effect and the duration of effectiveness. site was 2 cm above the top of the ear around the superior tempo-
ral line, and, in some cases, careful shaving was performed to keep
METHODS hairs from entering the anchoring site (Fig. 1).
After the design was made, liposuction was performed. A stab in-
This study was conducted by reviewing the charts of patients who cision was applied by an infra-auricular incision or infra-jowl incision
underwent thread lifting procedures between July 2013 and De- using a no. 11 scalpel blade, and 2.0 mL of lidocaine with 1:100,000
cember 2015. Patients’ medical records were reviewed retrospec-
tively for information including age, clinical photographs, the pro-
cedures undertaken, and any complications.
Patients with a follow-up period of at least 6 months were en-
rolled in this study. To assess skin laxity, preoperative grading was
performed using a 4-point scale (Table 1) [8].
Patients who had an active infectious disease that could alter
wound healing and operation outcomes, had a history of psychiat-
ric illness, or who had undergone previous facial procedures were
excluded from this study.
The patients were divided into two groups according to the sur-
gical procedure that was performed: thread lifting alone (group A)
or thread lifting with liposuction (group B). The requirement for Lateral canthus

informed consent was waived, and this investigation was approved

by the Institutional Review Board of Daegu Catholic University
Medical Center (IRB No. CR-19-027).
Mouth corner
Surgical techniques
Thread lifting with liposuction was performed using absorbable
thread lifting and temporal anchoring. The thread used in this study
was biodegradable polydioxanone minimal invasive nonsurgical
thread (MINT Lift ML-1043; Hans Biomed, Seoul, Korea) and ome-
ga 41 (OV World, Seoul, Korea).
The preoperative design was made with the patient in an upright
sitting position. We performed a preoperative pinch test and marked
Fig. 1. A design for thread lifting with liposuction. The area for lipo-
the boundary for liposuction depending on the amount of fatty tis- suction was marked depending on the amount of fatty tissue (red
sue present. The exit points of the threads were between the follow- area). The anchoring site was around the superior temporal line (blue
ing two lines: one from the lateral canthus to the submandibular area). The exit point of the threads was in the area where liposuction
angle, and the other a vertical line from the lateral canthus. The in- was performed (white circle).

Table 1. Skin laxity grading scale [8]

Grade Descriptive parameter Laxity

0 None None
1 Mild Localized to nasolabial folds
1.5 Mild Localized, nasolabial folds, early melolabial folds
2 Moderate Localized, nasolabial folds / melolabial folds, early jowls, early submental / submandibular
2.5 Moderate Localized, prominent nasolabial folds / melolabial folds, jowls and submental / submandibular
3 Advanced Prominent nasolabial folds / melolabial folds, jowls and submental / submandibular, early neck strands
3.5 Advanced Deep nasolabial folds / melolabial folds, prominent jowls and submental / submandibular, prominent neck strands
4 Severe Marked nasolabial folds / melolabial folds, jowls and submental / submandibular, neck redundancy and strands

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epinephrine tumescent solution was then injected (approximately
20–30 mL on each side). After sufficient pretunneling through the
incision site, a 14-gauge spatula-type cannula was inserted for lipo-
suction. During this procedure, a pinch test was performed to pre-
vent formation of an irregular contour due to excessive liposuction.
After liposuction, absorbable threads were anchored in the deep
temporal fascia of the anchoring site near the superior temporal
line using curved needles. A threaded long needle was inserted into
the hole, passed through the subcutaneous layer, and taken out at
the designed exit point. By repeating this maneuver, a total of four
threads were inserted on each side. The excess threads at the exit
point were gently pulled and then cut out. The intermediate post-
operative dimple was resolved through manual compression.
For patients in group A, thread lifting using absorbable threads
was done in the same manner, but the liposuction process was omit-
ted, and the number of threads inserted on each side ranged from
eight to 14 depending on the facial surface area and the degree of
slack.
Evaluation of outcomes
In order to evaluate the outcomes of the procedures, the results
were measured using the global aesthetic improvement scale (GAIS),
which was used as a reference parameter (Table 2) [9]. The value
recorded was determined independently by three plastic surgeons
(DGH, YBL, and SEK). We also checked the patient’s subjective
satisfaction using a 4-point scale (1, unsatisfied; 2, a little unsatis-
fied; 3, a little satisfied; and 4, very satisfied).
RESULTS
Epidemiology
Of the patients who underwent thread lifting with or without lipo-
suction between July 2013 to May 2015, 27 were observed for at
least 6 months. Group A included 11 patients, and group B includ-
ed 16 patients. All patients were female, and their mean age was
43.03 (43.72 in group A and 42.56 in group B). There was no sig-
nificant difference in the mean skin laxity grade between each group
(2.31 in group A and 2.15 in group B). The average follow-up peri-
od was 8 months.
Surgical results
The mean GAIS score for the thread lifting with liposuction group
(group B) was 1.85, and the mean score for the thread lifting–only
group (group A) was 2.54. The mean satisfaction score was 3.06 in
group B, while the mean score in group A was 2.36 (Tables 3, 4).
There were no major complications requiring additional treatment,

Table 2. The global aesthetic improvement scale

Score Degree Description

1 Very much improved Optimal cosmetic result

2 Much improved Marked improvement of the appearance but not completely optimal
3 Improved Improvement of the appearance; better compared with the initial condition, but a touch-up is advised
4 No change The appearance remains substantially the same compared with the original condition
5 Worsen The appearance has worsened compared with the original condition

Table 3. Summary of the GAIS score and satisfaction score in the thread lifting–only group (groupA)
Age Follow-up period Skin laxity GAIS by GAIS by GAIS by Satisfaction
Patient no. Sex
(yr) (mon) grade surgeon 1 surgeon 2 surgeon 3 score

1 F 33 7 1.5 2 3 2 2
2 F 34 7 2 3 4 4 2
3 F 46 12 2 3 3 3 1
4 F 46 8 3 4 3 2 2
5 F 47 7 3 3 2 3 2
6 F 53 6 3.5 3 3 3 1
7 F 54 6 2.5 4 3 4 2
8 F 50 7 2.5 2 3 3 3
9 F 26 9 1.5 1 3 1 4
10 F 41 11 2 2 1 1 4
11 F 51 14 2 1 1 1 3

GAIS score: 1 (very much improved) to 5 (worsen); satisfaction score: 1 (unsatisfied) to 4 (very satisfied).
GAIS, global aesthetic improvement scale; F, female.

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Table 4. Summary of the GAIS score and satisfaction score in the thread lifting with liposuction group (group B)
Age Follow-up period Skin laxity GAIS by GAIS by GAIS by Satisfaction
Patient no. Sex
(yr) (mon) grade surgeon 1 surgeon 2 surgeon 3 score

1 F 39 6 2 1 1 2 4
2 F 26 7 1.5 1 2 2 2
3 F 47 6 2.5 2 1 1 4
4 F 54 7 3 1 1 1 4
5 F 25 15 1.5 1 2 1 2
6 F 41 8 2 2 1 3 3
7 F 49 6 2.5 1 1 3 4
8 F 50 11 2.5 1 2 1 4
9 F 60 9 2.5 2 1 2 2
10 F 61 12 3 1 3 2 4
11 F 28 7 1.5 1 2 1 4
12 F 46 6 3 3 3 2 4
13 F 43 7 2 3 2 1 2
14 F 40 24 1.5 1 1 2 4
15 F 49 7 2 4 3 3 1
16 F 23 12 1.5 4 4 3 1

GAIS score: 1 (very much improved) to 5 (worsen); satisfaction score: 1 (unsatisfied) to 4 (very satisfied).
GAIS, global aesthetic improvement scale; F, female.

A B C

Fig. 2. A 33-year-old patient had complaints about the fullness of her lower face. She underwent thread lifting only, using 10 threads on each
side. (A) Preoperative view. (B) At a 2-week follow-up, her lower face fullness had improved. (C) At a 3-month follow-up, she had persistent
lower face fullness.

such as thread exposure, alopecia, or parotid gland injury. Five pa-
tients in group A and two patients in group B complained of ec-
chymosis. The ecchymosis lasted up to 3 weeks and did not require
any treatment. All patients were able to return to their daily activi-
ties within 1 week of the procedure.
DISCUSSION
Due to the influence of mass media, recent standards of beauty
have focused on facial youthfulness. This trend, in combination
with the increasing life expectancy, have led to a rapid increase in

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A B C

Fig. 3. A 34-year-old patient had complaints about a jowly lower face. She underwent thread lifting only, using 10 threads on each side. (A) Pre-
operative view. (B) At a 1-month follow-up, her jowly lower face had improved. (C) At a 4-month follow-up, she still had lower face jowls.

A B C

Fig. 4. A 28-year-old patient had complaints about lower face fullness. She underwent thread lifting using 4 threads on each side with liposuc-
tion. (A) Preoperative view. (B) A 1-week follow-up shows improved lower face fullness. (C) At a 7-month follow-up, the facial rejuvenating ef-
fect remained.

the number of operations and procedures related to facial rejuve-
nation [1,2]. In recent years, minimally invasive facial rejuvenation
has come into the spotlight because of the low incidence of compli-
cations and the patient’s rapid return to a normal daily routine.
Thread lifting is used to improve the appearance of aging in the
lower face, jaw line, malar fat pad, and mid-face. Techniques of
thread lifting for various applications, such as eyebrow lifting, neck
lifting, and sub-mental lifting, have been developed [10]. However,
a still-controversial disadvantage of the thread lifting procedure is
its short-lasting facial rejuvenating effect.
Rachel et al. [11] reported that the incidence of early recurrence
was 45% when an anchored barbed suture was used. They also ar-
gued that barbed sutures did not satisfy the patients’ needs, alth­
ough it was associated with lower morbidity and led to less down-
time for the patients. Kaminer et al. [12] reported an average of
11.5 months of patient satisfaction after procedures using anchored

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Bae KI et al. Thread lift with liposuction
A B
Fig. 5. A 54-year-old patient had complaints about lower face fullness and a jowly chin. She underwent thread lifting using 4 threads on each
side with liposuction. (A) Preoperative view. (B) A 1-month follow-up view shows much improved lower facial aging. (C) A 7-month follow-up
view shows that the lower facial rejuvenating effect persisted.
barbed sutures. In this study, the result of procedure with only
thread lifting alone shows early recurrence (Fig. 2) and short-last-
ing facial rejuvenating effect (Fig. 3). Abraham et al. [5] suggested
that thread lifting procedures have poor sustainability and are not
suitable for facial rejuvenation because they do not cause a volu-
metric change in the facial area; instead, they only change the posi-
tion of soft tissue in the superficial plane. In view of this, attempts
have been made to improve the effectiveness of thread lifting by
using other procedures in parallel, including fat grafts, filler injec-
tions, and laser treatment [6,7].
Liposuction for facial rejuvenation is known to be useful. Shu
and Lam [13] reported that liposuction using the tumescent tech-
nique was effective for facelifts in patients with thick and elastic
skin, unlike that of Caucasians. When liposuction of the facial area
is performed, amount of adipose tissue removed should not be
more than 70%. In the case of patients who are 50 or more years
old, skin laxity should be reduced to 50%, and the lip region should
not be suctioned.
Before performing the procedures, we assessed patients’ skin
laxity using the skin laxity grading scale designed by Alexiades-Ar-
menakas et al. [8] to avoid bias related to skin laxity. The mean
score for preoperative skin laxity was 2.31 and 2.15 in group A and
group B, respectively, and there was no significant difference be-
tween the two groups.
After these procedures, the mean score on the GAIS assigned by
three plastic surgeons was 1.85 for group B, corresponding to bet-
ter results than were obtained for group A (2.54). Furthermore, pa-
tients’ satisfaction scores were higher in the combined procedure
aaps Archives of
Aesthetic Plastic Surgery
C
group than in the control group. Thus, the GAIS outcomes corre-
sponded to the patients’ subjective satisfaction.
As Abraham et al. [5] argued, thread lifting alone cannot induce
volumetric change and has less efficacy for facial rejuvenation, but
this weak point could be supplemented and resolved by combining
thread lifting with a liposuction procedure. In our study, the result
of thread lifting combined with liposuction shows good sustain-
ability (Fig. 4) and improved effectiveness of thread lifting (Fig. 5).
In liposuction procedures, when the fatty layer is infused with a
tumescent solution, the fat cells are broken apart and emulsify into
the infusion fluid. These emulsified fatty cells can be easily removed,
causing not only a volumetric reduction, but also shrinkage and
tightening in the tissue layer during the healing process.
Liposuction also has complications, such as infection, postoper-
ative subcutaneous panniculitis-like reaction, and skin retraction
[14]. However, in this study, patients who underwent thread lifting
with liposuction complained only of self-resolving problems, such
as ecchymosis, and there were no complications requiring specific
treatments. Thus, thread lifting combined with liposuction appears
to be minimally invasive and has few complications, although it is
necessary to investigate this issue further with a larger number of
patients.
Throughout the course of the healing process, thread lifting com-
bined with liposuction resulted in better clinical outcomes than
thread lifting alone, and showed effectiveness over a long-term fol-
low-up of more than 6 months.
However, to enable a more accurate comparison, a further study
should be designed with more subjects, and such a study would
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preferably incorporate an objective evaluation technique using a 3. Holliday R, Elfving-Hwang J. Gender, globalization and aesthetic sur-
recently developed skin diagnosis system in addition to the GAIS gery in South Korea. Body Soc 2012;18:58-81.
score [15]. 4. Sulamanidze M, Sulamanidze G, Vozdvizhensky I, et al. Avoiding com-
In conclusion, patients who underwent thread lifting combined plications with Aptos sutures. Aesthet Surg J 2011;31:863-73.
with liposuction showed greater satisfaction and better GAIS scores 5. Abraham RF, DeFatta RJ, Williams EF 3rd. Thread-lift for facial reju-
than those who received thread lifting only, even after a long fol- venation: assessment of long-term results. Arch Facial Plast Surg 2009;
low-up period. 11:178-83.
6. Williams EF 3rd, Smith SP Jr. Minimally invasive midfacial rejuvena-
NOTES tion: combining thread-lift and lipotransfer. Facial Plast Surg Clin
North Am 2007;15:209-19.
Conflict of interest 7. Holcomb JD. Laser-assisted facelift. Facial Plast Surg 2014;30:405-12.
No potential conflict of interest relevant to this article was reported. 8. Alexiades-Armenakas M, Rosenberg D, Renton B, et al. Blinded, ran-
domized, quantitative grading comparison of minimally invasive,
Ethical approval fractional radiofrequency and surgical face-lift to treat skin laxity.
The study was approved by the Institutional Review Board of Daegu Arch Dermatol 2010;146:396-405.
Catholic University Medical Center (IRB No. CR-19-027) and per- 9. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blind, mul-
formed in accordance with the principles of the Declaration of ticenter comparison of the efficacy and tolerability of Restylane versus
Helsinki. Zyplast for the correction of nasolabial folds. Dermatol Surg 2003;29:
588-95.
Patient consent 10. Yongtrakul P, Sirithanabadeekul P, Siriphan P. Thread lift: classifica-
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tion and the use of their images. Eng Technol 2016;10:558-66.
11. Rachel JD, Lack EB, Larson B. Incidence of complications and early
ORCID recurrence in 29 patients after facial rejuvenation with barbed suture
Kwang Il Bae https://orcid.org/0000-0003-4496-2159 lifting. Dermatol Surg 2010;36:348-54.
Dong Gil Han https://orcid.org/0000-0001-7922-5859 12. Kaminer MS, Bogart M, Choi C, et al. Long-term efficacy of anchored
Sung-Eun Kim https://orcid.org/0000-0002-3413-7094 barbed sutures in the face and neck. Dermatol Surg 2008;34:1041-7.
Young Bae Lee https://orcid.org/0000-0001-6879-0094 13. Shu T, Lam SM. Liposuction and lipotransplants for facial rejuvena-
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